Anand Gopal, MD
Wills Eye Hospital
Despite advances in surgical technique, rhegmatogenous retinal detachments (RRD) associated with giant retinal tears (GRT) pose a significant challenge to surgeons due to the technical difficulty of repair and high rates of re-detachment.
Dr. J. Fernando Arevalo of the Wilmer Eye Institute at Johns Hopkins University opened the Macula 2022 Conference at Wills Eye Hospital with an elucidating presentation on the management of GRT-related RRDs. Dr. Arevalo reported the results of a large international multicenter retrospective cohort study characterizing practice patterns for GRT-related RRD repair.
The study compared anatomic and functional outcomes between eyes undergoing pars plana vitrectomy (PPV) alone versus combined pars plana vitrectomy/scleral buckle (PPV/SB). Patients undergoing GRT-related RRD repair across 7 participating institutions between 2008 and 2020 with at least 6-months follow-up were included.
In their analysis of 200 eyes, Arevalo and colleagues found comparable rates of PPV and PPV/SB utilization for GRT RRD repair. No differences in baseline demographic or ocular characteristics were noted between the two groups. Overall anatomic success rates between eyes undergoing PPV versus PPV/SB were similar at 6 months and 1 year, even among adult phakic eyes with inferior pathology. The most common cause of re-detachment was proliferative vitreoretinopathy (Grade C or worse). No differences in rates of post-operative complications between surgical techniques were observed.
Intriguingly, in a sub-analysis of pediatric patients, a significantly higher rate of single surgery anatomic success was observed among eyes undergoing PPV/SB, noting that pediatric eyes overall had worse presenting vision, higher rates of macular involvement, larger detachments, and more frequent history of associated trauma.
The authors hypothesized that the benefit of combined PPV/SB in children may derive from several factors. First, complete vitreous shaving in pediatric eyes is challenging due to the presence of the native lens. Second, children may be less likely than adults to adhere to post-operative positioning. Third, the vitreous in children is inherently more “tenacious,” as Arevalo described, increasing the difficulty of inducing a posterior vitreous detachment and removing vitreous gel. For these reasons, scleral buckling in children may afford the supplemental benefits of reducing vitreoretinal traction and supporting retinal breaks. In adults with GRTs, these benefits may be obviated by the intrinsic release of traction that such large tears provide, Arevalo explained.
By offering illuminating insights on the management of GRT-related RRDs, Dr. Arevalo’s talk set the stage for subsequent lively discussion. As members of the audience noted, further work is needed to better understand and guide surgical management of these challenging detachments.
